Professor Affette McCaw-Binns, a Reproductive Health Epidemiologist at the University of the West Indies (Mona) and Dr Simone Spence, Director of Family Health Services at the Ministry of Health in Jamaica explain how legislation and policy strengthened the reporting of maternal deaths in Jamaica. This case study describes how the policy framework was amended to improve the reporting of maternal deaths and how other interventions implemented simultaneously together strengthen the maternal death surveillance and response (MDSR) system.
In the early 1980s1,2, maternal deaths in Jamaica were significantly under-reported in vital registration records by as much as 75%. With over 80% of all live births occurring in public hospitals2 it was suggested that establishing a surveillance system at public hospitals could capture needed information about the number of maternal deaths in the country. Given the findings3, the government agreed to implement an active (as opposed to the pre-existing passive) surveillance system to monitor maternal deaths.
This case study will describe the approaches that the government adopted, including how the legal framework was used in support of strengthening the MDSR system and reversing under-reporting.Continue reading →
This analysis of the findings of the national confidential enquiry around maternal deaths conducted the Ministry of Health in Morocco shows that 54.3% of the deaths analysed in 2009 could have been avoided if appropriate action had been taken at health facilities.
This contradicted previous beliefs that the main causes of maternal death were due to women delaying seeking care. Lack of competence or motivation of staff were linked to the majority of cases of substandard care these women received.
The authors recommend that the managers of local health systems and practitioners themselves received the information and means to support them to implement the recommendations of the audits.
This study highlights the importance of involving hospitals and health providers in the audit process and particularly in supporting them to respond to findings.
This paper by Dr Paily and colleagues, describes the processes and findings from the Confidential Review of Maternal Deaths (CRMD) in Kerala, India.
The paper describes how actions and recommendations were developed based on the findings, and how the response and monitoring has conducted a pilot phase to support continuous improvements in the delivery of quality of care.
One of the key lessons learnt relates to the importance of raising awareness among administrators as a key group who can support the process of CRMDs as members of the multi-disciplinary team.
The MDSR system in Malaysia is often referred to as a model upon which other countries can learn about how success can be achieved with limited resources. To support other countries in taking forward MDSRs, the Government and Ministry of Health of Malaysia are actively supporting implementation in Lao PDR, Vietnam and Nepal with regular visits conducted by Dr Ravichandran Jeganathan, the National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia. Dr Jeganathan summarised the focus of his advocacy during the Lao PDR meeting as a call for ensuring adequate skilled birth attendance for each community at village level by ensuring that each village to have at least one midwife.
During these visits, local teams are guided in how to adapt and develop tools to conduct the investigation process, and have been trained how to conduct maternal death reviews. Specific attention is given to clarify the concept of a non-punitive approach and how the response mechanism can be implemented and achieved with ease, even with minimal resources. Dr Jeganathan is a keen advocate for including medical and nursing students on the training to ensure their exposure to the concept of MDSRs early on in their career.
In Malaysia, the sixth edition of theReport on the Confidential Enquiries into Maternal Deaths in Malaysia 2009 – 2011 that was in progress during the last newsletter is now available upon request.
In addition, a near miss registry is being finalised; parameters have been identified and tools drafted. This near miss approach will be piloted in one district hospital in September 2016 to ascertain its validity.
This country update was informed by feedback from Dr Ravichandran Jeganathan, the National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia.
For previous countryupdatesof Malaysia and acase studywritten by Dr Jeganathan, follow the links or visit the MDSR Action Network website.
We asked six experts from Malaysia, Ireland, Ethiopia and India about the importance of multi-disciplinary teams in maternal death surveillance and response (MDSR) systems. Here are the insights they shared with us.
Our contributors have all worked closely with MDSR (or maternal death review also known as MDR, which is a component of MDSR) in various guises, contexts and parts of the world. We have drawn together common themes from their insights to draw out lessons learned for the successful implementation of multi-disciplinary health actor involvement in MDSR.
In 2009, the Government of Malawi established the National Committee on Confidential Enquiry into Maternal Deaths. The Committee are tasked with producing national reports on maternal deaths in a given time period in order to guide actions and responses to prevent future maternal deaths. The first report produced by the Committee investigates maternal deaths that took place between 2008 and 2012.
The retrospective review of records from 27/28 districts included 1433 maternal deaths that took place in facilities or en route to a facility between 2008-2012 (inc.). In total, 57% were due to direct causes including haemorrhage (14% of all maternal deaths), pre-eclampsia (14%), sepsis (10%), and abortion (10%). Key indirect causes of deaths included: anaemia (19%), malaria (15%), and HIV/AIDS (8%).
The report, made public in May 2015, explains the methods of the enquiry, presents the findings, and provides recommendations for action.
This case study is an excerpt from a collection of 22 case studies by the Evidence for Action-MamaYe! programme based on their experiences. These case studies bring to light new learning about the specific ways in which evidence, advocacy and accountability must work together to bring about change.
Evidence for Action-MamaYe! was established in 2011 through funding from the UK Department of International Development. The programme’s goal is to save maternal and newborn lives in Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone and Tanzania, through better resource allocation and improved quality of care.
When the Evidence for Action-MamaYe (E4A) programme first started operations in Malawi, we observed that while some facilities and districts were carrying out maternal death reviews, committees met only rarely and did not communicate systematically with other levels. Rudimentary action plans were sometimes developed, but there were no follow-up meetings to track change. Furthermore, the maternal death review process did not include the community level. Consequently, community factors that might have contributed to facility deaths and maternal deaths occurring within communities were not recorded, no explanation was fed back to families or communities on the reasons for facility-based deaths, and no actions were taken in response. This led to distrust between community members and facility staff, who themselves often blamed the families for bringing the woman to the facility too late. Continue reading →
This article by Felix Sayinzoga and colleagues, published by BMJ Open in January 2016, presents the findings of a review of all health facility-based maternal death audits in Rwanda between January 2009 and December 2013. Based on this review, the authors found that the facility-based maternal death audit approach has helped facility teams to identity causes of death and contributing factors, as well as make recommendations for action to prevent future deaths. They recommend that Rwanda better inform corrective actions by complementing these audits with other strategies, such as confidential enquiries and near-miss audits
This article by Heather Scott and colleagues, published by the Journal of Obstetrics and Gynecology Canada in October 2015, provides an overview of the status of MDSR implementation in East and Southern Africa by presenting key findings from 1) a knowledge-sharing regional meeting in Johannesburg, South Africa in November 2014, and 2) an evaluation of the Confidential Enquiry into Maternal Deaths in South Africa by UNFPA. The authors found that MDSR is still not at an optimal level in many countries in sub-Saharan Africa. More work by national authorities, communities, and development organisations is needed, particularly in addressing key challenges.
Kerala has been successful in establishing a Confidential Enquiry into Maternal Deaths (CEMD), learning from the system in the United Kingdom. You can read here more about the main causes of maternal deaths in Kerala, the challenges in establishing the CEMD system, and ways forward to make it more efficient.